When Enough is Enough: Ultrasound-Guided Ascent Into Heaven
Ashley C. Barfield
April 4, 2007
Winston Counterman14-year-old miniature Schnauzer
• Several months of weight loss
• Vomiting 2-3 times a day for 3 days
• Decreased energy
• Small amount of diarrhea for 3 days
• Recent diet change
Labwork Abnormalities
CBC• Mild leukocytosis• Moderate anemia• Severe
thrombocytopenia
Chemistry• BUN = 50• ALKP = 272• AMYL = 1287• TGL = 214• ALB = 1.9
Radiographic Abnormality
RDVM noted decreased serosal detail consistent with abdominal effusion
The Good Stuff
Large heterogenous splenic mass and multiple heterogenous nodules
Large heterogenous hepatic mass and multiple nodules
Liver…It’s So Good
Kidney: Not just for breakfast anymore
Bilaterally decreased corticomedullary definition, multiple heterogenous nodules, multiple cysts, one hypoechoic nodule
And the Badness
Grossly enlarged and heterogenous right medial iliac lymph node
The Sauce
Large amount of echogenic peritoneal fluid, consistent with hemorrhage (accompanied by a normal pancreas); aspiration yielded fluid hemorrhagic in appearance
Interpretation
“These findings are consistent with metastatic neoplasia.”
-- Tony Pease DVM MS
How to Save Winston?• Aspirates of liver, spleen, kidney, lymph node
• Thoracic radiographs (additional met check)
• Transfusion and surgical resection of bleeding mass
• Surgical resection/debulking of other masses
• Chemotherapy and radiation therapy based on histopath results
• Serial imaging to monitor progress during therapy
Winston’s owner elected humane euthanasia to prevent further suffering.
Pumpkin Rogers12 year-old spayed DSH
• 6-month history of chronic weight loss
• Watery diarrhea of unknown duration
• No change in appetite or energy level
• No PU/PD or vomiting
• FELV/FIV negative indoor cat
Labwork Abnormalities
CBC• Mild normochromic,
normocytic anemia• Thrombocytopenia• Hypoproteinemia• Stress leukogram
(elevated SEGS & monos, decreased lymphs)
Chemistry• Hypoalbuminemia• Hypoglobulinemia• Mildly elevated ALT• Mildly elevated ALKP
Labwork Abnormalities
Urinalysis• 1+ proteinuria• 4+ bilirubinuria
T4 = 0.53 (1-4)
Again, the Good Stuff
Mildly thickened small and large intestinal walls
Bowel walls also fluid-filled
Top differentials:• Neoplasia• Inflammatory
bowel disease
Hyperechoic kidneys with decreased corticomedullary distinction
Hypoechoic liver
Peritoneal fluid & possible pancreatic edema
IBD or Lymphoma?
• Full-thickness or endoscopic intestinal biopsies
• Mesenteric lymph node aspirates
• Liver and kidney aspirates
What if it’s the big K?Met check/staging• Thoracic rads• Peripheral lymph node aspirates• Serial imaging during therapy
Prognosis• 6 months to >2 years • severity of disease (histopathologic grade and tumor
phenotype)
• response to chemotherapy
Pumpkin’s Situation
• Loss of 50% of body mass in 6 months
• Potential involvement of liver and kidneys
• Owners elected no further diagnostics
• Owners elected pred and ice cream therapy
Pumpkin died at home the next day
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